UPDATED 4/22/2016 All Level Contracts
PROTECTIVE LIFE
Contracting Checklist
Agent/Agency: ____________________________________________
Direct Upline: ____________________________________________
Documents To Be Completed & Returned:
Agent Transmittal
Agent Application
Authorization and Certification of Statements
W-9 Form
Individual State License(s)
Corporate State License(s) (If Applicable)
Proof of E&O
Assignment of Commissions (OPTIONAL) (For assigning commissions to agency, but the
agent will be responsible for the 1099.)
Independent Agents Annualization Agreement (OPTIONAL)
Commission Direct Deposit w/Voided Check (OPTIONAL)
SEND TO:
Mail: Attention: Life Licensing
American Brokerage Services
803 East Willow Grove Avenue
Wyndmoor, PA 19038
Email: [email protected]
Type of Contract:
New - For type of contract refer to the Agent Application
Contract Change: Agent Number ______________________________ Direct Marketer
Hierarchy:
Brokerage General Agent
Sub Brokerage General Agent
Recruiting Agent
Producing Agent
Soliciting Agent
If Soliciting Agent, Pay Commissions To:
Send Mail to: The BGA The Agent The SubBGA
For rates please consult your Commission Summary Grid. Dual Contracting rules apply.
(A) (B) Schedules offered are A or B for Life and default to A for Annuities
Schedules A, B and C can be recruiter schedules.
(A) (B) (C)
Agent Commission Schedule: (A) (B) (C) (D)
(E) (F) (G) (H)
Annualization: Yes No (75%)
Special Instructions or Comments:
PL - Agent Transmittal
Agent Transmittal
A Solicitors hierarchy will mirror where commissions are paid.
Recruiter Schedules: (Check One) SubBGA Schedules: (Check One)
Name
______________________________________________
______________________________________________
Agent Number ________________________
If schedule A is selected and the agent is not a Solicitor, they will automatically be setup as a Recruiter.
______________________________________________ (100%) (Check One) ______________________________________________ 11/2014 _______________________________________________________________ _________________________________________ ________________________________________ (Check One) (50%)
If Yes, BGA must complete Life Commission Annualization/Chargeback Addendum (ANN-PL 8/11) and the Independent Agent Annualization Agreement (PL Agent Annualization Agreement 07/2011).
BGA/SubBGA Name Date
E-mail all documents to [email protected] or fax to 205-268-6831.
_________________________ _________________________ _________________________ _________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ______________________________________________ (Check One)
OAKTREE FINANCIAL GROUP
000T000361
AMERICAN BROKERAGE SERVICES
000T000383
✔
Type of Contract: (choose one)
o Business
o Business with Soliciting Principal
o Individual
o Solicitor
Preferred Name Birth Date Place of Birth
(mm/dd/yyyy)
Designations:
If Soliciting Agent, Pay Commissions To: _______________________________________________________
_____________________________________________ _____________________________________________ Business Name (If Applicable) Business Type (Inc., Sole Proprietor, Partnership): _____________________________________________ _____________________________________________
Business Mailing Address Business Street Address (If Different)
_____________________________________________ _____________________________________________
Street / P.O. Box Street / P.O. Box
_____________________________________________ _____________________________________________
Suite Suite
________________________ _______ ___________ __________________________ __________________
City State Zip City State Zip
Residence Phone _____________________________________________
Street / P.O. Box Business Phone
_____________________________________________ Suite
________________________ _______ ___________ Business 800 Number
City State Zip
What is your target market? Business Fax Number
o Middle o Upper Middle o Other
How many years have you been licensed? _________
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
If this application is for a Corporation, please supply Tax ID:
___ ___ - ___ ___ ___ ___ ___ ___ ___ Email Address (Mandatory)
Residence
Spouse
PL- Agent Application 08/2011 Social Security No.
First Name/Middle Name/Last Name
o CLU o ChFC o CFP o MDRT o NQA o Other ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Gender: o Male o Female
Read carefully and please answer the following:
If any changes occur after the date of this application, please notify Protective Life immediately.
o
1. Have you ever been or are you currently contracted with Protective Life Insurance Company?
o Yes o No
2. Do you hold a Securities license?
o Yes o No
If "Yes", please provide your Broker/Dealer name.
3. May Protective Life publicize your name and photo in Company publications?
o Yes o No
4. Is your agency owned by a bank or credit union or will sales of the life or annuity products be transacted in a bank or credit union?
o Yes o No
If "Yes", please explain.
5. Are you currently, or have you ever been a party to a lawsuit, arbitration or other legal or judicial proceeding?
o Yes o No
If "Yes", please explain.
6. Have you ever had an insurance license denied, revoked or suspended?
o Yes o No
If "Yes", please explain.
7. Are you currently being investigated or have you ever had any disciplinary action taken against you or terminated other than for lack of production by another insurance company, a state insurance department, the NASD, SEC or any other regulatory authority?
o Yes o No
If "Yes", please explain. I agree
8. Have you ever filed for bankruptcy or do you currently owe any money to or have a debit balance with another insurance company?
o Yes o No
If "Yes", please explain.
9. Have you ever been convicted of (or plead no contest to) a felony or misdemeanor?
*The Federal Violent Crime Control & Law Enforcement Act of 1994 prevents people who have been convicted of a felony from participating in the business of insurance.
o Yes o No
If "Yes", please explain.
10. Have you ever had a claim against your errors and omissions policy?
o Yes o No
If "Yes", please explain.
11. Have you had a complaint filed against you in the past ten years that resulted in a fine or penalty, censure, cease and desist order, or consent order?
o Yes o No
If "Yes", please explain.
12. Have you completed Anti-Money Laundering in the past 24 months?
o Yes o No
If Yes, with whom? Please attach certificate if other than LIMRA.
Weekly Direct Deposit for Commissions: (Preferred method) Yes ___ No ___. If Yes, complete
the PL-DIR-DEP 08/2011 form and attach. (Producers not on Direct Deposit will be sent a check only at month end. A minimum commissions payable amount of $100 is required before a check will be sent.) Errors & Omissions Coverage
Carrier Name: ________________________________________________________
I attest I will maintain Errors and Omissions insurance with a liability limit of $1,000,000 or greater. I also agree to provide evidence of such coverage to the Company when requested. Failure to maintain adequate Errors and Omissions coverage may result in the suspension or termination of this Agreement.
PL- Agent Application 08/2011 Liability Amount: _______________________________________________
Policy Effective Date: _________________________________
1.
2. To provide competent and customer-focused sales and service. 3. To engage in active and fair competition.
4. To provide advertising and sales materials that are clear as to purpose and honest and fair as to content. 5. To provide for fair and expeditious handling of customer complaints and disputes.
6.
I agree that authorizations granted herein will continue as long as I am contracted with Protective.
Date Applicant Signature
Authorization and Certification of Statements
I hereby apply to Protective Life Insurance Company ("Protective") to sell life and other insurance products. If this application is accepted, I agree to solicit business for Protective in accordance with the terms of the Independent Agent Agreement or the Independent Soliciting Agent Agreement, the terms of which are incorporated into this application by reference. I agree Protective has no obligation to approve this application and I release Protective from all liability if it does not contract me. I agree to take all steps reasonably necessary to become and remain knowledgeable about all Protective products that I sell. I agree not to solicit business for Protective until I am properly licensed and/or
appointed, unless allowed by law to do so in a given state.
Protective is committed to providing customer-focused service founded on our three preeminent values of Quality, Serving People, and Growth. Protective expects you to follow in the ethical conduct of business. Protective has also committed itself to uphold the ACLI Market Conduct Principles listed below. Your signature below indicates your
agreement to read and follow Protective's guidelines and the ACLI Market Conduct Principles. I further agree to follow the guidelines outlined in the Ethical Market Conduct Guidelines which are included in the complete contract packet.
To conduct business according to high standards of honesty and fairness and to render that service to its customers which, in the same circumstances, it would apply to or demand for itself.
PL-Independent Agent Application - Authorization and Certification 08/2011 To maintain a system of supervision and review that is reasonably designed to achieve compliance with these Principles of Ethical Market Conduct.
I hereby certify that the statements contained in the Application are true and complete to the best of my knowledge and belief. I understand that any false statement on the application may be considered as sufficient cause for rejection of this application or for termination if such statement is later discovered to be false.
I authorize Protective to obtain background information about me that includes, but is not limited to: a credit report, criminal background report, a report of debit balances with other insurance carriers, and a report of state, federal disciplinary actions against me. I understand that Protective will use this information to determine my suitability to represent Protective.
Information furnished in this application or derived from other sources may be shared with individuals and entities involved in your recruitment to Protective. I understand that background information gathered about me will not be shared with me, and that in the event my application is denied, I may request copies of my background information provided to Protective by reporting agencies directly from those agencies.
Entered into this day of ________________________ between PROTECTIVE LIFE INSURANCE COMPANY and
_________________________________________________________________.
1) The Company agrees to make certain advances against first year commissions resulting from new business personally produced by the Agent.
2) Payments to the Agent will be made on policies issued and paid for at the home office of the Company on the following basis:
a. Only policies on monthly pre-authorized withdrawal will be annualized. b. Maximum commission advance on any one case will be $7,500. c. Agents must be on direct deposit.
3) This financing arrangement will apply to all new business except annuities, group insurance, special marketing programs and business on the life of the Agent and the Agent's immediate family.
4) The agent acknowledges that all amounts paid to the Agent in excess of the Agent's commission on the amount actually paid by the policyholder will constitute a debt to the Company and to guarantor, if named below. In the event of termination of the Independent Agent's Agreement, the amount of the loan then outstanding will immed-iately become a demand note (irrespective of any commission which may be payable after termination) and will bear interest at the rate of 8% per annum until the entire indebtedness has been liquidated.
5) The Company will have the right to apply any commission thereafter accruing to Agent against the loan. Nothing contained in this Agreement will be construed as an amendment to the Independent Agent's Agreement.
6) Both parties reserve the right to terminate this Agreement at any time.
____________________________________________________________________
Agent Signature
____________________________________________________________________ Barry K. Brown, 2nd Vice President
Licensing, Contracting and Compensation PROTECTIVE LIFE INSURANCE COMPANY
I guarantee the repayment to the Company any and all sums, which the Company may from time to time advance to the Agent, named above in accordance with the terms of the above Agreement. I consent to any and all exten-sions of time, which the Company may grant to the Agent from time to time for repayment of such sums.
____________________________________________________________________ ____________________
Signature of Guarantor Date
PL Agent Annualization Agreement 07/2011
(herein referred to as Agent)
(herein referred to as Company) (date)
1. Annualization 1. 2. 3. 4. 2. Indebtedness
BGA Name: (Please Print) _____________________________________________
ANN-PL (8/11)
Life Commission Annualization/Chargeback Addendum
This Addendum is hereby made a part of the Brokerage General Agent (BGA) agreement and you and Protective Life Insurance Company (Company), and is subject to all terms and conditions of the Agreement.
The Company agrees to annualize first-year commissions that would otherwise be payable to your agents subject to the following provisions:
Annualized commission shall only be paid on policies actually issued by the Company on which the first premium is paid.
Commissions shall be annualized only on premium payment modes approved by the Company. Commissions on modes not approved for annualization shall be paid to your agent as premiums are received by the Company. Commissions shall not be annualized on direct pay modes or on post-dated checks.
The maximum annualized commissions payable under this Addendum shall be subject to any per policy, monthly, or other maximums, restrictions or guidelines established by the Company.
The Company reserves the right to change, alter or modify its policies and procedures regarding the annualization of commissions at any time.
If a policy on which annualized commissions have been paid lapses, is not taken, is cancelled, is otherwise terminated, does not become effective for any reason, or is changed to a non-annualized mode of premium payment within the first policy year, all unearned commissions shall be charged back to your agent and shall be considered to be an indebtedness owed to the Company. If after 60 days, a debit balance has not been cleared from other commission payments or paid back by your agent, we will deduct that amount from your commission payments per your Brokerage General Agent Agreement.
In the event a fixed life insurance policy shall terminate within six months from issue, the full compensation paid thereon shall be charged back. In the event a termination takes place after the sixth month and before the thirteenth month after the date of issue, fifty percent of the compensation will be charged back.
Agent Name: (Please Print) ____________________________________________ Agent # _____________________
BGA Signature: ______________________________________________________ Date: ________________________
any, for agent # _________________________________.
from all liability to the Assignor for the payment of such commissions to the same extent as if payment had been made directly to the Assignor.
assignment of interest in the commissions herein assigned.
Company.
Signature of Assignor Date
not assume responsibility for the validity or legality thereof.
Barry K. Brown, 2nd Vice President Date
Licensing, Contracting and Compensation PROTECTIVE LIFE INSURANCE COMPANY
PL - Assignment of Commissions 07/2011
become due PROTECTIVE LIFE INSURANCE COMPANY from the Assignor, and is also subject to prior
ASSIGNMENT OF COMMISSIONS
I, ________________________________________________________ (Assignor), for valuable consideration which I acknowledge to be sufficient, hereby assign and transfer to ____________________________________________________ (Assignee), any and all first year and renewal commissions now due me or hereafter to become due under the terms and provisions of the Independent Agent's Agreement entered into between me and PROTECTIVE LIFE
This Agreement will remain in effect until revoked by the Assignee by giving written notice to the
NOTE: Earnings on commissions will be reported to the Internal Revenue Service for the party (Assignor) who signed the Agreement on which commissions are being paid. A notation will be made on the 1099 form indicating that commissions were assigned.
PROTECTIVE LIFE INSURANCE COMPANY acknowledges receipt of this Assignment of Commissions, but does INSURANCE COMPANY dated ________________________________ and all supplements and amendments, if
Payment of said commission to the Assignee shall discharge PROTECTIVE LIFE INSURANCE COMPANY
Please complete this form and return it to the following address:
Financial Institution Name
Routing Number
Your Signature Print Name Date
PL DIR DEP 08/2011
This authority will remain in effect until Protective Life Insurance Company has received written notification from me that I wish to discontinue participation in the Commission Direct Deposit program.
COMMISSION DIRECT DEPOSIT
With Protective Life's Commission Direct Deposit, your commission earnings will be deposited directly into the account specified below.
Protective Life Insurance Company Commission Service Department E-mail: [email protected]
For Business or Individuals receiving commission, please complete this form.
(Soliciting Agents should not complete this form.)
Fax: (205) 268-3169
Commission Direct Deposit Authorization
I authorize Protective Life Insurance Company to initiate entries and to initiate, if necessary, a debit entry for any credit entry made in error to the account listed below.